Provider Demographics
NPI:1225004294
Name:BORODULIA, NICHOLAS NICHOLSON (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:NICHOLSON
Last Name:BORODULIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12036 S PINEY POINT RD
Mailing Address - Street 2:
Mailing Address - City:BISHOPVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21813-1542
Mailing Address - Country:US
Mailing Address - Phone:302-581-0458
Mailing Address - Fax:302-581-0460
Practice Address - Street 1:1400 COASTAL HWY
Practice Address - Street 2:
Practice Address - City:FENWICK ISLAND
Practice Address - State:DE
Practice Address - Zip Code:19944-4452
Practice Address - Country:US
Practice Address - Phone:302-581-0458
Practice Address - Fax:302-581-0460
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10001802207Q00000X
MDD0028769207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE412338Medicare ID - Type Unspecified
DEB66599Medicare UPIN
MD314PMedicare PIN